'Going rural': driving change through a rural medical education innovation.

INTRODUCTION: Medical education across the globe is in a state of flux influenced by a number of drivers for change. In response, institutions are seeking to re-align their curricula to address the prevailing imperatives. Against this backdrop, the training of practitioners for practice in rural communities was identified as an educational priority, and led to the establishment of a rural clinical school (RCS) within a Faculty of Medicine and Health Sciences in South Africa in 2011. This article describes the students' experiences in the first year that this innovative educational model was implemented and explores the extent to which it influenced their thinking and practice. METHODS: A qualitative, formative evaluation study of the first year of implementation was undertaken. Data was generated from in-depth interviews. This article focuses on individual interviews conducted with the eight students at the RCS, which explored their experiences during a year-long clerkship. Transcripts of interviews were thematically analysed. RESULTS: Four themes emerged from the analysis: a learning experience that differed from what was experienced at the tertiary training hospital, an enabling clinical environment in the district and regional hospital, the positive role played by the specialists, and the influence of the community immersion. Underlying all of the responses was the building of relationships over time both with supervisors and with patients. Evident from the responses was that students' confidence in their clinical skills and decision-making abilities was heightened while their approaches to their own learning were enhanced. CONCLUSIONS: To respond to the call for educational reform and a heightened awareness of social realities, innovative approaches to the training of medical students, such as those adopted at the RCS, are indicated. It is argued that the learning facilitated by these rural medical education models has the potential to offer learning experiences that can lead to transformation through a change in practice and attitude among the students, and ultimately also enable curricular renewal at the institutional core.

Perceived educational value and enjoyment of a rural clinical rotation for medical students.

INTRODUCTION: It is well-recognised that medical students whose training exposure is largely limited to tertiary-level training hospitals may be inappropriately equipped to deal with the most relevant health issues affecting rural communities. This article evaluated the perceived educational value of a 2 week clinical rotation undertaken by senior undergraduate medical students at rural district hospitals and health care centers in the Western Cape Province, South Africa. METHODS: Students completed a daily log diary to provide an overview of time spent on specific academic activities, ranking the educational and enjoyment value of each activity. At the end of the 2 week rotation students completed an open-ended questionnaire capturing the main positive and negative aspects of their experience, followed by focus group discussions with a randomly selected subgroup. In addition, a formal feedback seminar was arranged with the academic supervisors at each of the training sites to triangulate the information received and to document their perspective. RESULTS: Thirty-seven students consented to study participation and 25 (68%) adequately completed the log diaries and questionnaires, rating the following activities as most educational: 'assisting in theatre', 'teaching by doctor', 'seeing patients in clinic/health centre/OPD' and 'mobile clinic excursions'. The rural experience allowed practical application of their theoretical knowledge, which improved their levels of confidence and enjoyment. The most enjoyed activities were: 'mobile clinic excursions', 'performing medical procedures' and 'teaching by doctor'. The students were critical of some aspects: (i) the rural rotation was not structured efficiently; (ii) compulsory written reports and additional projects prevented them from maximizing the rural experience; and (iii) a time period of 2 weeks was felt to be too short for optimum benefit from the rotation. CONCLUSION: The feedback obtained from this log diary study demonstrates that well-functioning rural health care centers provide excellent opportunities for students to develop the most relevant practical skills required of generalist doctors working in resource-limited settings. In addition to a more efficiently structured rural program, students requested an increase in the length of the rotation and a reduction in the written academic workload.

A qualitative study on the relationship between doctors and nurses offering primary health at KwaNobuhle (Uitenhage)

"Background Primary health care; which was the domain of the nursing profession; was popularised by the introduction of free health services by the South African legislature. In addition; the district health system was developed with the aim of keeping people healthy by creating small management systems adapted to cater for local needs. These measures increased public access to healthcare centres; leading to an increased workload at primary health level. The government; being a large organisation; relies on groups that include doctors and nurses to accomplish its goals; and the effectiveness of these groups plays a major role in determining the effectiveness of the overall organization. ""The nurse has an ethical responsibility in the interest of the welfare of her patient to be a loyal and competent colleague to the doctor. The nurse and the doctor must be able to rely on each other. Mutual respect is vital."" Nurses have dependent; independent and interdependent roles in their interaction with doctors; and both professions should embrace the Patient's Rights Charter; which requires a good standard of practice and care of patients. International journals have published numerous letters citing doctor-nurse disagreements in their interactions. Historically; the doctor-nurse relationship is an unequal one characterised by the dominance of the doctor; with nurses assuming a position of lower status and dependence on physicians. One qualitative study showed that nurses perceive the quality of communication with doctors as being poor. Lack of teamwork in the relationship resulted from different expectations and a confusion of roles. Both professions have however demonstrated a willingness to promote teamwork in hospitals. A journal review on interventions to promote collaboration between nurses and doctors showed positive gains once collaboration was embraced. Method This was a descriptive qualitative study in which the experiences of Kwa-Nobuhle general practitioners and professional nurses were explored. An equal number of nurses and doctors (five each) were purposefully selected; for the free-attitude interviews used for data collection. All interviews were analysed using the thematic analysis method. Themes were integrated into a single model. Results Majority of respondents experienced a relatively good relationship. The positive factors were balanced by negative experiences by almost all respondents. The positives were personal growth; efficiency at work; opportunity for education and learning at the primary healthcare level. The negatives were doctors' inconsistent clinic visits; role confusion (with doctors being confused with policymakers); dominance of the doctor in the relationship; and lack of doctor-nurse forums for communication; with subsequent suspicion and tension. The impact of the conflicts was neutralised by the track record of the relationship and the behaviour of the participants towards each other. Conclusion This study showed congruence with other studies; where the doctor-nurse relationship was influenced by a power differential;collaboration; role confusion; impact of the respondents' com etence; the significance of recognising the nurses' hierarchy and continuity of the care they provide at the primary health level. Maximum variation; strict admission criteria and data validation through a member check addressed issues of bias in this study. The exploration of relationships is a sensitive issue and a different methodology may produce different results. The environment where this research was conducted may differ from others; leading to discrepancies in findings. Future research could further focus on team building and the essential elements to sustain the doctor-nurse-patient team."

A Qualitative Study on the Relationship between Doctors and Nurses Offering Primary Health at KwaNobuhle (Uitenhage)

"Background: Primary health care; which was the domain of the nursing profession; was popularised by the introduction of free health services by the South African legislature. In addition; the district health system was developed with the aim of keeping people healthy by creating small management systems adapted to cater for local needs. These measures increased public access to healthcare centres; leading to an increased workload at primary health level. The government; being a large organisation; relies on groups that include doctors and nurses to accomplish its goals; and the governess of these groups plays a major role in determining the effectiveness of the overall organization. ""The nurse has an ethical responsibility in the interest of the welfare of her patient to be a loyal and petent colleague to the doctor. The nurse and the doctor must be able to rely on each other. Mutual respect is vital."" Nurses have dependent; independent and interdependent roles in their interaction with doctors; and both professions should embrace the Patient's Rights Charter; which requires a good standard of practice and care of patients. International journals have published numerous letters citing doctor-nurse disagreements in their interactions. Historically; the doctor-nurse relationship is an unequal one characterised by the dominance of the doctor; with nurses assuming a position of lower status and dependence on physicians. One qualitative study showed that nurses perceive the quality of communication with doctors as being poor. Lack of teamwork in the relationship resulted from different expectations and a confusion of roles. Both professions have however demonstrated a willingness to promote teamwork in hospitals. A journal review on interventions to promote collaboration between nurses and doctors showed positive gains once collaboration was embraced.Method: This was a descriptive qualitative study in which the experiences of Kwa-Nobuhle general practitioners and professional nurses were explored. An equal number of nurses and doctors (five each) were purposefully selected; for the free-attitude interviews used for data collection. All interviews were analysed using the thematic analysis method. Themes were integrated into a single Model.Results: Majority of respondents experienced a relatively good relationship. The positive factors were balanced by negative experiences by almost all respondents. The positives were personal growth; efficiency at work; opportunity for education and learning at the primary healthcare level. The negatives were doctors' inconsistent clinic visits; role confusion (with doctors being confused with policymakers); dominance of the doctor in the relationship; and lack of doctor-nurse forums for communication; with subsequent suspicion and tension. The impact of the conflicts was neutralised by the track record of the relationship and the behaviour of the participants towards each other.Conclusion: This study showed congruence with other studies; where the doctor-nurse relationship was influenced by a power differential; collaboration; role confusion; impact of the respondents' competence; the significance of recognising the nurses' hierarchy and continuity of the care they provide at the primary health level. Maximum variation; strict admission criteria and data validation through a member check addressed issues of bias in this study. The exploration of relationships is a sensitive issue and a different methodology may produce different results. The environment where this research was conducted may differ from others; leading to discrepancies in findings. Future research could further focus on team building and the essential elements to sustain the doctor-nurse-patient team."

Village health-workers and GOBI-FFF. An evaluation of a rural programme.

Growth monitoring, oral rehydration, breast-feeding and immunisation--female education, family spacing and food supplementation (GOBI-FFF) are a selective package of World Health Organisation primary health care strategies recommended by UNICEF. Changes over a 1-year period in the implementation of the components of GOBI-FFF were investigated in a rural village in Ciskei to detect any changes associated with a newly modified village health-worker (VHW) programme. A baseline survey was conducted before the introduction of a modified VHW programme and a second survey took place a year later. The principles of GOBI-FFF were already familiar to and have since been increasingly practised by the community and health personnel. Breast-feeding is widespread, most carers know how to make oral rehydration solution and most children have a 'Road to Health' card and are being weighed regularly. However, malnutrition remains a major problem and the food supplementation programme is operating poorly. The high coverage of the community by the village health-workers and the clinic suggest that these two channels should be used more intensively to strengthen the GOBI-FFF programme in the area.